Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing from this site. If a form is not available electronically, you will be provided instructions for requesting a paper copy. If you are searching for a form number that does not start with the letter "F," just enter the number you have available and you will get a better search result. Example, looking for DDE-2539? Enter "2539" in the Search Forms field below.

The Division of Health Care Access and Accountability (DHCAA) and Division of Long Term Care (DLTC) have combined into the Division of Medicaid Services (DMS). When searching for forms by Division, please use the new acronym.

Assigned Number Title Division Other Location
F-40064 Transfer of the Emergency Food Assistance Program (TEFAP) Commodities between EFOs DPH
F-01204C Letter - IRIS Program Notice of Action - Reduction DMS
F-02008 CLTS Waivers Certification Exam DMS
F-01159 Commercial Other Coverage Discrepancy Report DMS
F-20817 Assessment Worksheet for Natural Residential Setting DMS
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS
F-62696 Student Nurse / Graduate Nurse Verification DQA
F-00842 Pharmacy Services Lock-In Program - Program Summary DMS
F-13023 Medicaid Purchase Plan Premium - Member / Employer Electronic Funds Transfer and Instructions DMS
F-62156 Living Unit Direct Care Staff Report - Day Shift DQA
F-01781 Immunization Program Functional Exercise 2018-2019 (BP1 Supplemental) DPH
F-00468 Community Substance Abuse Services (CSAS) Medically Managed Inpatient Treatment Service Recertification Application - DHS 75.10 DQA
F-10192 Medicaid Annuity Information - Disclosure DMS
F-45008 Application for Radioactive Material License for Medical Use DPH
F-01566A IRIS Self-Directed Personal Care (SDPC) – Physician Order and Plan of Care DMS
F-00236 Request for a State Fair Hearing - MCO DMS
F-02107B Family Adult Day Care Center – Established Provider Certification Application Checklist DQA
F-05023 Acknowledgement of Marital Child DPH
F-62274A Personal Care Agency Consent for Home Visit DQA


Last Revised: March 26, 2019